mid2163 topic 3
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Notes about inflammationTRANSCRIPT
TOPIC 3:TOPIC 3:INFLAMMATIONINFLAMMATION
OBJECTIVES
Causes of inflammation Inflammation classifications
– Acute Inflammation– Chronic Inflammation
Systemic effects of inflammation
INFLAMMATION
Latin word, 'inflammare' = to burn Body's response to injury
DEFINITION:
− Local defence mechanism initiated by tissue injury
INFLAMMATION
Physiological response to tissue damage & accompanied by a characteristic series of local changes– Inflammatory reaction takes place in the
surviving adjacent vascular & connective tissues
INFLAMMATION
Purpose: Protection⇨to localize & isolate toxic substances⇨remove/destroy the injurious stimuli
(pathogens) and damaged tissue⇨initiate the healing and repair process –
remove the cellular debris from the area
NOMENCLATURE
Inflammatory lesion are usually indicated by the suffix ~'itis'
Example:⇨Appendicitis = inflammation of the appendix
⇨Meningitis = inflammation of the meninges
Some exceptions, example: pneumonia, typhoid fever
CAUSES
Physical agents→Mechanical injuries, alteration of temperature &
pressure, radiation injuries, ultraviolet
Chemical agents→Organic – microbial toxins & organic poisons
(weedkillers)
→ Inorganic – acids, alkaline, drugs
Biological agents/microbes→ Infectious = bacteria, viruses, fungi, protozoa
CAUSES
Immunologic disorders→Hypersensitivity reactions, autoimmunity,
immunodificiency states
Genetic/metabolic disorders→ Gout, diabetes mellitus
Antigens that stimulate immunological response
CLASSIFICATIONS
CLASSIFICATION
Based on duration of the lesion and histologic appearances
2 classifications⇨Acute inflammation⇨Chronic inflammation
ACUTE INFLAMMATION
ACUTE INFLAMMATION
Immediate & early response to an injurious agent = protective response!
→Early vascular response and late cell response
Relatively non-specific response
→eliminate dead tissue, protect against local infection & allows immune system to response = beneficial
ACUTE INFLAMMATION
Relatively short duration
→ lasting for minutes, several hours of a few days
→ may range from normal to severe
ACUTE INFLAMMATION
5 cardinal signs
1)Rubor
2)Calor
3)Tumor
4)Dolor
5)Functio laesa- latin words
ACUTE iNFLAMMATION
1) Rubor Redness Due to dilation of small blood vessels within
damaged tissue as it occurs in cellulitis by the action of mediators
*cellulitis: inflammation spread to the connective tissue
ACUTE iNFLAMMATION
2) Calor Heat Results from increased blood flow
(hyperemia) due to: regional vascular dilation cellular metabolism
ACUTE iNFLAMMATION
3) Tumor Swelling Due to accumulation of fluid in the
extravascular space = increased vascular permeability
ACUTE iNFLAMMATION
4) Dolor Pain Partly results from the stretching &
destruction of tissues due to inflammatory edema & part from pus under pressure in as abcess cavity
Some chemicals of acute inflammation are also known to induce pain Bradykinins, prostaglandin & serotonin
ACUTE iNFLAMMATION
5) Functio leasa Loss of function Inflamed area is inhibited by pain while
severe swelling may also physically immobilize the tissue
Steps of Acute Inflammation
Steps of acute inflammation
1) Increased blood flow = hyperemia
2) Exudation of fluids & plasma proteins Exudate: discharge of fluid or substances from cells
or blood vessels onto the skin or organ surface
3) Emigration of leucocytes
Capillaries become engorged & dilated with blood (congestion)
Leakage of fluids and protein into the tissues = infiltration of leukocytes into the
area of injury
Leukocytes engulf and digest the pathogens and help remove it from the area
(phagocytosis)
1) Hyperemia
(a) Injured tissues by any agents
(b) Following injury, both the arterioles supplying the damaged area and local capillaries dilate – increasing blood flow to the site
• this causes redness (rubor) & increased heat (calor) in the affected region
1) Hyperemia
Caused mainly by local released of a number of chemical mediators from damaged cells
Mast cells release histamine in response to tissue injury or infection
INJURY
Damaged Cells
CHEMICAL MEDIATORS
VASCULAR DILATATION
Direct effect on vessels
Nervous reaction (axon reflex)
2) Exudation of Fluids
* Exudation: increased passage of protein-rich fluid through the vessel wall into the interstitial tissue
Fluid leaving local blood vessels & entering interstitial space = swelling / oedema
Caused by → Increased permeability of small blood
vessels wall
→ Increased hydrostatic pressure
2) Exudation of Fluids
INCREASED PERMEABILITY
Caused by→ inflammatory mediators released by
injured cells– prostaglandin, histamine & serotonin
→ cells that formed the single-layered venules pull apart from one another
2) Exudation of Fluids
INCREASED PERMEABILITY
The opening of channels that allow the movement of→ Excess fluid = leaves blood & enters
tissues
→ Plasma proteins =albumin, globulin etc – normally retained in bloodstream reduced osmotic pressure of blood
2) Exudation of Fluids
INCREASED HYDROSTATIC PRESSURE Increased blood flow into the capillary bed
forces fluid out of the vessels & into the tissues
Some interstitial fluid returns to capillaries but most of the inflammatory exudates, phagocytes & cell debris removed in lymph vessels
→ pores of the lymph vessels larger & pressure inside it is lower than blood capillaries
3) Emigration of Leukocytes
Loss of fluid→ thicken the blood
→ reduced the flow
→ allowing leukocytes make contact & adhere to the vessel wall = selectin & integrins
3) Emigration of Leukocytes
Most important leukocyte = neutrophil→ Adhere to the blood vessels lining
→ Squeeze between endothelial cells
→ Enters tissue and went to the inflamed area by chemotaxis
→ Main function: phagocytosis of antigen
3) Emigration of Leukocytes
Macrophages→ larger and longer lived than neutrophils
→ phagocytose dead/dying tissue, microbes & other antigenic material and dead/dying neutrophils
→ predominently in inflamed tissue after 24hours
→ persist in the tissue if the situation is not resolved = chronic inflammation
CHEMOTAXIS Movement of a motile cell/organism in a direction corresponding to a gradient of increasing or decreasing concentration of the particular chemotactic agent– Chemical attraction of leukocytes to an area of
inflammation
PHAGOCYTOSISCell eatingMacrophages & neutrophils attracted to the inflammatory & infectious site by chemotaxisChemo-attractans released by injured cells & invading microbesPhagocytes trap particles either by engulfing them with their body mass or by extending long psedopodia towards themNon-selective = bind, engulf and digest foreign cells or particles
CHEMICAL MEDIATORS Various chemical mediators have roles in inflammatory process They may be circulating in plasma and require activation or may be secreted by inflammatory cells
Mast cells = histamine Platelets = serotonin
Many of these mediators have overlapping actions
Vasodilating chemicals
Histamine, serotonin, bradykinins, prostaglandin
Chemotactic factors
Fibrin, collagen, mast cell, bacterial peptides
Substances with both vasodilating & chemotactic effects
Complement fragments of C5a and C3a, interferons, interleukines and platelet secretion
Chemical mediators of Inflammation
Morphology of Acute Inflammation
MORPHOLOGY
Involves production of exudates (edema fluid with high protein concentration, frquently contain inflammatory cells)
*Transudate? Non-inflammatory edema
Caused by cardiac, renal, undernutritional and other disorders
MORPHOLOGY
Different morphologic types of accute inflammationi. Serous inflammation - watery
ii. Fibrinous inflammation - haemorrhagic
iii.Suppurative (purulent) inflammation - pus
iv.Catharral inflammation – mucous membrane
v. Pseudomembranous inflammation
BLISTER, “Watery”, i.e., SEROUS
i. Serous Inflammation
Characterized by an outpouring of a thin fluid that is derived from either the blood serum or secretion of mesothelial cells lining the peritoneal, pleural, and pericardial cavities
It resolves without reactions
FIBRINOUS
ii. Fibrinous Inflammation More severe injuries Result in greater vascular permeability that
ultimately leads to exudation of larger molecules such as fibrinogens through the vascular barrier
Fibrinous exudate is characteristic of inflammation in serous body cavities such as the pericardium (butter and bread appearance) and pleura
ii. Fibrinous Inflammation
Course of fibrous inflammation include:– Resolution by fibrinolysis– Scar formation between perietal and
visceral surfaces i.e. the exudates get organized
– Fibrous strand formation that bridges the pericardial space
PUS
=
PURULENT
ABSCESS
=
OF
PUS
iii. Suppurative Inflammation
Characterized by the production of a large amount of pus– Pus is a thick creamy liquid, yellowish or
blood stained in colour and composed of• A large number of living or dead
leukocytes (pus cells)• Necrotic tissue debris• Living and dead bacteria• Edema fluid
iii. Suppurative Inflammation
2 types:
A) Abscess formation:– abscess = a circumscribed accumulation of pus
in a living tissue
– encapsulated by a so-called pyogenic membrane, which consists of layers of fibrin, inflammatory cells and granulation tissue
iii. Suppurative Inflammation
2 types:
B) Acute diffuse (phlegmonous) inflammation– characterized by diffuse spread of the exudate
through tissue spaces
– caused by virulent bacteria (eg. streptococci) without either localization or marked pus formation
– example: Cellulitis (in palmar spaces)
iv. Catharral Inflammation
Mild and superficial inflammation of the mucous membrane
Commonly seen in the upper respiratory tract following viral infections where mucous secreting glands are present in large numbers
example: Rhinitis.
v. Pseudomembranous Inflammation
Basic elements – extensive confluent necrosis of the
surface epithelium of an inflamed mucosa – severe acute inflammation of the
underlying tissues The fibrinogens in the inflamed tissue
coagulate within the necrotic epithelium
v. Pseudomembranous Inflammation
Fibrinogen, necrotic epithelium, neutrophilic polymorphs, red blood cells, bacteria and tissue debris form a false (pseudo) membrane = forms a white or colored layer over the surface of inflamed mucosa
Example:– Dipthetric infection of the pharynx or larynx
– Clostridium difficille infection in the large bowel following certain antibiotic use
Effects of Acute Inflammation
EFFECTS
2 types of effects
(a) Beneficial effects
(b) Harmful effects
BENEFICIAL EFFECTS
a) Dilution of toxins:
►concentration of chemical and bacterial toxins at the site of inflammation reduced by dilution in the exudate
►removal from the site by the flow of exudates from the venules through the tissue to the lymphatic
BENEFICIAL EFFECTS
b) Protective antibodies:
►Formation of tissue exudation allows protective proteins including antibodies at the site of inflammation
►Thus, antibodies promote microbial destruction by phagocytosis or complement-mediated cell lysis = neutralise their toxins
BENEFICIAL EFFECTS(c)Fibrin formation:
– Tissue damage is repaired and scars can form if fibroblasts are involved.
BENEFICIAL EFFECTS
d) Promotion of phagocytosis►Neutrophils & macrophages actively
recruited to the inflamed areas = engulf biological & non-biological origin
►Phagocyte activity promoted by increasing temperature (local & systemic)
►Phagocytes may die at the inflamed area if the material they ingest resist digestion or excessive = disintegrate & released material that cause further damage
BENEFICIAL EFFECTS
e) Cell nutrition: ►The flow of inflammatory exudates brings
with it glucose, oxygen and other nutrients to meet the metabolic requirements of the greatly increased number of cells
►It also removes their solute waste products via lymphatic channels
BENEFICIAL EFFECTS
f) Promotion of immunity: ►Micro-organisms and their toxins are carried
by the exudates, either free or in phagocytes, along the lymphatics to local lymph nodes
• they stimulate an immune response with the generation of antibodies and cellular immune mechanisms of defence
HARMFUL EFFECTS
Tissue swelling⇨Result of the increased blood flow &
exudation⇨Often accompanies by loss of function⇨Effects can be harmful = depending on the
site• Joint = limitation of movement• Larynx = interference with breathing
HARMFUL EFFECTS
Pain⇨Occurs when local swelling compress
sensory nerve endings⇨Exacerbated by chemical mediators of the
inflammatory process that potentiate the sensitivity of the sensory nerve endings
• Bradykinin• Prostaglandin
Course of Acute Inflammation
COURSE OF ACUTE INFLAMMATION
possible outcomes depend on removal of inflammatory exudate and replacement by either regenerated cells or scar tissue 4 possible outcomes
(1) Resolution
(2) Healing by fibrosis
(3) Abscess formation
(4) Chronic inflammation
COURSE OF ACUTE INFLAMMATION
Factors affecting outcome of acute inflammation
(1) severity of tissue damage
(2) capacity of stem cells to divide
(3) type of agent causing damage
(1)Resolution
involves complete restitution of normal architecture and function 3 main features which potentiate this sequel are
→ Minimal cell death & tissue damage
→ Rapid elimination of the causal agent
→ Local conditions favouring of fluid & debris
(1)Resolution
Inflammatory process is reversed and→ damaged cells are phagocytosed
→ fibrin strands are broken down by fibrinolytic enzymes
→ waste material is removed in lymph and blood vessels
→ repair is complete leaving only a small car
(1)Resolution
Arises from damage to parenchyma in labile/stable tissues
cells replaced by regeneration normal function restored
Can only occur if the connective tissue framework of the tissue is intact & the tissue involved has the capacity to replace any specialised cells that have been lost
(2)Healing by Fibrosis Occurs when
connective tissue framework damage tissue lacks the ability to regenerate
specialised cells 1St: dead tissues & acute inflammatory exudate removed by macrophages Defect filled by ingrowth of a specialised vascular connective tissue called granulation tissue
(2)Healing by Fibrosis granulation tissue - gradually produces collagen = form a fibrous (collagenous) scar = repair loss of some specialised cells & some architectural distortion by fibrous scar = structural integrity is re-established any impairment of function = dependent on the extent of loss of specialised cells
(2)Healing by Fibrosis Modified forms of repair occur in
► bone after a fracture when new bone is created
► brain with the formation of an astrocytic scar
(3)Abscess Formation Takes place when
acute inflammatory reaction fails to destroy/remove the cause of tissue damage
continues with a component of chronic inflammation
Most common: infection by pyogenic bacteria As the acute inflammation progresses, there is liquefaction of the tissue to form pus Peripherally, a chronic inflammatory component & fibrous tissue surrounds the area = localising puss
(3)Abscess Formation If abscess left untreated, it can lead to
sinus formation fistula formation
(3)Abscess FormationSinus
tract lined by granulation tissue leading from a chronically inflamed cavity
to a surface cause the continuing presence of foreign or
necrotic material Example: sinus associated with
osteomyelitis & pilonidal sinus
A pilonidal dimple is a small pit or sinus in the sacral area just at the top of the crease between the buttocks - deep tract, rather than a shallow depression, leading to a sinus that may contain hair. During adolescence the pilonidal dimple or tract may become infected forming a cyst-like structure called a pilonidal cyst = may require surgical drainage or total excision to prevent reinfection
(3)Abscess FormationFistula
tract open at both ends Abnormal communication b etween two
surfaces is established 2 main types
congenital = development abnormality acquired = trauma, inflammation or necrosis
(4)Chronic Inflammation May result following acute inflammation when an injurious agent persists over a prolonged period Causing concomitant tissue destruction, inflammation, organisation and repair Some injurious agents induced a chronic inflammatory type of response from the outset
CHRONIC INFLAMMATION
CHRONIC INFLAMMATIONprolonged inflammatory process (weeks or months) where an active
inflammation, tissue destruction and attempts at repair are proceeding
simultaneously
Causes
Persistent infections
→Certain microorganisms associated with intracellular infection = tuberculosis, leprosy, certain fungi characterictically cause chronic inflammation
→These organisms have low tosicity and evoke delayed hypersensitivity reactions
Causes
Prolonged exposure to nondegradable but partially toxic substances
→endogenous lipid components which result in atherosclerosis
→exogenous substances such as silica, asbestos
Causes
Progression from acute inflammation
→acute inflammation almost always progresses to chronic inflammation following persistent suppuration as a result of
• uncollapsed abscess cavities• foreign body materials (dirt, cloth, wool,
etc)• sequesterum in osteomylitis• sinus/fistula from chronic abscesses
Causes
Autoimmunity
→autoimmune diseases such as rheumatoid arthritis and systemic lupus erythematosis are chronic inflammations from the outset
Morphology
Cells of chronic inflammation– Monocytes & macrophages = main
cells– T-lymphocytes– B-lymphocytes & plasma
Classification
Classified into 2 types based on histologic features
1. Non-specific chronic inflammation2. Specific inflammation
(granulomatous inflammation)
Classification
1. Non-specific chronic inflammation– involves a diffuse accumulation of
macrophages and lymphocytes at site of injury that is usually productive with new fibrous tissue formations
– example: Chronic cholecystitis.
Classification
2. Specific inflammation– Granulomatous inflammation– characterized by the presence of
granuloma• granuloma is a microscopic aggregate of
epithelioid cells (modified macrophages)
Classification
2. Specific inflammation– Epithelioid cell
• is an activated macrophage, with a modified epithelial cell-like appearance (hence the name epithelioid)
• can fuse with each other & form multinucleated giant cells – foreign body-type giant cells & Langhans giant cells
Classification
2. Specific inflammation– granuloma is basically a collection of
epithelioid cells, it also usually contains multinucleated giant cell & is usually surrounded by a cuff of lymphocytes and occasional plasma cells
Pathogenesis
2 types of granuloma
1. Foreign body granuloma2. Immune granuloma
Pathogenesis
1.Foreign body granuloma– initiated by inert foreign bodies such as
talc, sutures (nonabsorbable), fibers, etc…– these foreign bodies are large enough to
preclude phagocytosis by a single macrophage and do not incite an immune response
Pathogenesis
2.Immune granulomas– antigen presenting cells (macrophages) engulf a
poorly soluble inciting agent
– then, the macrophage processes and presents part of the antigen and activated lymphocytes
– the activated lymphocytes produce cytokines that activate another lymphocytes = transform macrophages into epitheloid & multinucleated giant cells & maintain the granuloma
– Macrophage inhibitory factor helps to localize activated macrophages & epitheloid cells
Causes Major causes of granulomatious inflammation:
– Bacterial: Tuberculosis, Leprosy, Syphilis, Cat scratch disease, Yersiniosis
– Fungal: Histoplasmosis, Cryptococcosis, Coccidioidomycosis, Blastomycosis
– Helminthic: Schistosomiasis
– Protozoal: Leishmaniasis, Toxoplasmosis
– Chlamydia: Lymphogranuloma venerum
– Inorganic material: Berrylliosis
– Idiopathic: Acidosis, Cohn’s disease, Primary biliary cirrhosis
SYSTEMIC EFFECTS OF INFLAMMATION
Systemic effects of Inflammation
Include 1. Fever
2. Endocrine & metabolic responses
3. Autonomic responses
4. Behavioural responses
5. Leukocytosis
6. Leukopenia
7. Weight loss
1.Fever most important systemic manifestation of
inflammation. It is coordinated by the hypothalamus & by cytokines released from macrophages and other cells
2. Endocrine & metabolic responses the liver secrets acute phase proteins such as C-
reactive proteins, Serum Amyloid A, complement and coagulation proteins
Glucocorticoids (increased) Vasopressin (decreased)
3. Autonomic responses redirection of blood flow from the cutaneous to
the deep vascular bed pulse rate and blood pressure (increased) sweating (decreased)
4. Behavioural responses Rigor, chills, anoroxia, somnolence and malaise
5. Leukocytosis also a common feature of inflammation,
especially in bacterial infections its usual count is 15,000 to 20,000 cells/mm3 most bacterial infections induce neutrophilia some viral infections such as infectious
mononucleosis, & mumps cause lymphocytosis parasitic infestations & allergic reactions such
as bronchial ashma & hay fever induce eosinophilia
6. Leukopenia Also a feature of thyphoid fever and some
parasitic infections
7. Weight loss Catabolism of skeletal muscle, adipose tissue
and the liver with resultant negative nitrogen balance